In the U.S., nearly 500,000 patients suffer an ST-elevation myocardial infarction (STEMI) each year. Most emergency departments (EDs) lack the local capabilities to perform the definitive treatment, primary percutaneous coronary intervention (PCI). Thus, patients must be transferred to capable facilities, but inefficiencies in this process cause delays in timely reperfusion of coronary vessels and worsen patient outcomes. The time to reperfusion for transferred STEMI patients greatly lags behind those patients who present directly to PCI centers and fails to meet national benchmark standards in 90% of cases. Inadequate measurement and understanding of the timing and processes of care at referring EDs have hindered improvement in the timeliness of STEMI patient transfer. The study of coordination, communication, and organizational design, collectively known as organizational behavior, is an accepted approach to study performance and variation in complex health systems. It has not yet been applied to the transfer of STEMI patients, but would likely reveal important targets for intervention. This proposal describes a career development plan that enables the candidate to gain expertise in organizational behavior through the acquisition of advanced qualitative and quantitative skills for future implementation studies. The Specific Aims are: a) Examine referring ED operational data for candidate measures of timeliness and factors associated with reduced time to coronary reperfusion; b) Conduct a detailed qualitative assessment of the organizational behavior at referring EDs that transfer patients for primary PCI; and c) Examine the association between organizational behavior and time spent at referring EDs. The candidate is uniquely qualified as an emergency physician and PhD candidate in operations management. The career development plan builds on this foundation to provide: a) advanced skills in qualitative methods (e.g., patient and staff interviewing skills, and observation), biostatistics, and organizational theory; b) further development of scientific communication skills through manuscript preparation, grant writing, and conference presentations; and c) a multidisciplinary mentored research experience with international experts in transitions of care, qualitative research, process intervention development, and trial design. The institutional environment is outstanding, including an innovative qualitative research center; nationally ranked graduate programs in the candidate's fields of study; and the national CTSA coordinating center. This career development award will allow the candidate to develop expertise in how to measure the performance of healthcare systems during inter-facility transfer, a deep understanding of the relationship between system performance and patient outcomes, and targets for intervention to improve the timeliness of care for myocardial infarction. This award will successfully position the candidate to become an R01-funded independent investigator who implements and evaluates process interventions to improve patient outcomes.